Becoming a Neurosurgeon

By John Colapinto

A fascinating guide to a career in neurosurgery written by award-winning journalist John Colapinto and based on the real-life experiences of an expert in the field—essential reading for someone considering a path to this most challenging profession.

Choosing what to do with your life begins with imagining yourself in a career, actually meeting the emotional, physical, and intellectual demands of the job. Often regarded as one of the most technically and emotionally demanding of surgical disciplines, becoming a neurosurgeon requires years of study. This practical guide offers a unique opportunity to see what daily life for a neurosurgeon is like, from someone who has mastered the profession and can explain what the risks and rewards of the job really are.

Joshua Bederson is the chief of Neurosurgery at the esteemed Mt. Sinai Hospital in New York City. New Yorker writer John Colapinto brings to vivid life what Dr. Bederson’s professional life is like to show all the varied facets of his work, from extensive study and research to brain operations, one-on-one consultations with patients, and even staff meetings with fellow surgeons and students. Since Mt. Sinai is a teaching hospital, we learn alongside the residents and interns how Bederson trains neurosurgeons, passing along the knowledge and skills he honed over decades. The result is a multidimensional portrait of a man and a department, a practical guide for how to enter and learn the profession, as well as a moving glimpse into the world of patients and doctors who face some of life’s most harrowing challenges.

• Language: English
• Publisher: Simon & Schuster
• Release date: Apr 2, 2019
• ISBN: 9781501159190

John Colapinto

John Colapinto has written for Vanity Fair, The New Yorker, Esquire, Mademoiselle, Us Weekly, and Rolling Stone, where the landmark National Magazine Award-winning article that was the basis for As Nature Made Him first appeared. He is also the author of the novel About the Author. He lives in New York City with his wife and son.

Book preview

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It is 8:33 a.m. and Dr. Amir Madani, a neurosurgery resident at Mount Sinai, the large teaching hospital on Manhattan’s Upper East Side, is about to perform the final operation in his training as a brain surgeon. A team of doctors and nurses, eight people in all, dressed in blue scrubs and white paper face masks, move around Operating Room #2, preparing equipment, as the patient, a forty-year-old African-American woman, is wheeled in on a gurney. She is transferred onto an operating table in the center of the room, and the anesthesiologist inserts an IV needle into her right arm. He begins a drip of propofol, a powerful sedative. Within seconds, she is unconscious. A nurse, standing between the patient’s legs, places a catheter to drain urine during what is expected to be a four-hour-long operation. The scrub nurse arranges instruments—scalpels, forceps, sponges—on a large table beside the bed. Once all is in readiness, the neurosurgery resident, Dr. Madani, a tall, sad-eyed man in his late thirties, ties a surgical mask over his face and steps over to the sleeping patient.

Okay, he says, let’s do this.

Neurosurgery residency, the training period for brain surgeons after their four years of medical school, is the most grueling in all of medicine. Trainees work upward of 120 hours a week, often on as little as one or two hours of sleep a night. They do this for seven years, the longest of any surgical specialty. This will be Madani’s 1,807th operation at Mount Sinai, and his 180th assisting Dr. Joshua Bederson, the chairman of the department of neurosurgery.

It is a remarkable case on which to be going out. The patient had been in an accident six months earlier, hit in her car by a pickup that tried to swerve around her at a red light. A minor case of whiplash prompted a CT scan of her head and neck—which revealed, serendipitously, a massive brain tumor the size of a man’s fist in her left frontal lobe, just above the eye. The tumor’s spherical, self-contained shape suggested that it was of a slow-growing type that had, in all likelihood, been expanding for decades. The tumor now threatened to crowd out the healthy tissues (which have little room to expand within the closed box of the skull), inducing swelling that could cause her brain, squeezed like toothpaste in a tube, to herniate—to push out through the hole where her skull joins the spine. This would crush the brain stem, the seat of such vital functions as breathing and heartbeat—instantly killing her.

Three months ago, in early March, Bederson, with Madani assisting, had eliminated the immediate danger to the patient by opening her skull, cutting a tiny two-centimeter slit in the surface of the brain, and decompressing the tumor by draining it of a watery yellow liquid that had been building up. They then removed the growth. Such tumors, however, are encapsulated in a thin skin or rind. The patient was now scheduled to have that rind removed, since a biopsy showed that it contained pre-cancerous cells.

The patient had, in the meantime, undergone a complete transformation. For her entire adult life, she had been antisocial, depressed, lethargic, spending the better part of the previous twenty-three years on the sofa watching television. In the months since that first operation, she had begun rising early to exercise and had shed fifty pounds. She now took intense pleasure in every aspect of her life—especially her two children, seventeen and fourteen years old, for whom she had performed parental duties like preparing meals but from whom she had been emotionally isolated and distant. She could now barely restrain herself from constantly kissing and touching them, as if discovering them for the first time. She felt the same way about her husband. They had met when she was eighteen years old and fallen in love, but she had shown little real affection toward him since 1996, when they married.

Neurosurgeons have long known about the changes in mood and personality that can take place through manipulation of the frontal lobes, but rarely does a patient show so dramatic a change in temperament and outlook as had occurred in this case—especially so soon after treatment. While coming out of the anesthetic after the initial operation, she began laughing and pointing at the anesthetist and loudly, playfully proclaiming, I know you! I know you! The surgical staff dubbed her The Giggler because of her infectious, easily triggered laugh. At the time of her second surgery, to remove the tumor lining, she was making plans to enroll in nursing school. She had given up coffee, after a decades-long addiction, and wine. She no longer watched TV—too busy exercising, talking, reading, living. Old texts on her smartphone—messages filled with bitterness, despair, and deep pessimism—mystified her. I don’t know who that person is, she said, before going into the second operation. I know it was me, but it doesn’t seem possible.

•  •  •

IN THE OPERATING ROOM Madani tapes a pair of latex-free plastic strips over the patient’s eyes. He talks as he works. There is a fascinating account of frontal lobe surgery in Penfield’s letters, he says, referring to Wilder Penfield, the early-twentieth-century physician recognized to be one of the grandfathers of modern neurosurgery. "In the late 1920s, he operated on his sister and removed a frontal lobe tumor. After doing the routine post-op tests in the hospital, he said, ‘Oh she’s doing really well.’ But later, he was at her house and saw that the place was incredibly messy, she couldn’t manage two things at a time. She was confused, disoriented. She’d always been meticulously organized. He realized that the frontal lobe is extremely important, but mysterious. Almost a century later, we’re still so ignorant about what the frontal lobe does—or how it does it."

The same could be said for the brain as a whole: a three-pound lump of jelly-like matter whose hundred billion cells, and the trillions of electrochemical connections between them, make up the most complex system in the known universe. This system is responsible not only for all motor and sensory functions of the body but for the mystery of consciousness itself and all to which it gives rise: love, hope, memory, fear, music, poetry, art, science—everything, in short, that makes us human. That so little is known about the anatomy and functioning of the brain is one reason neurosurgery is so demanding and so dangerous. Those who expose and cut into the brain’s tissues are, to a very real degree, traveling in terra incognita. Indeed, so fraught with risk is opening the skull and invading the brain—where a millimeter’s error can spell disaster—no reasonable medical professional would perform these interventions save for the fact that patients who end up in neurosurgery wards are already suffering from calamities so threatening to their life and well-being that nonintervention is not an option.

With this patient, Madani goes on, gesturing at the woman on the table, "there was a huge mass that we decompressed in her frontal lobe. So the pressure of that tumor was affecting the neuronal communication in a very complex way, and it altered her personality. But how? Who knows? Was the tumor suppressing the electrical activity of the cells by squashing the frontal lobe against the inside of the skull? Maybe. Or maybe the tumor was secreting some chemical agents that interfere. On a molecular level there is so much going on that we cannot see with our imaging tools—and that we’ll maybe never know."

He wields a hairbrush to make a part in the patient’s hair, exposing a long thin scar from the earlier operation. The scar arcs over the top of her head from temple to temple, about an inch behind the hairline. As he works, he says, wistfully, This is the last time I’ll do this at Mount Sinai.

A nurse, who sits in a corner monitoring the patient’s brain activity on a computer, asks what he plans to do next.

Me? Madani deadpans, as he brushes an antiseptic gel into the patient’s hair. I’ll be opening a barbershop. Doing similar stuff, just slightly less stressful. Laughter fills the room.

No, he continues, I’m going to spend two years in Toronto doing a fellowship in deep brain stimulation. (DBS involves inserting electrodes into the brain to stimulate areas associated with movement disorders like Parkinson’s Disease and mood disorders like depression.) That means, Madani says, "that, by the time I finish my neurosurgical education, I will have been in school for twenty-one years after high school. This includes four years pre-med in math and biochemistry at Columbia University, eight years of medical school to obtain a combined MD and PhD at SUNY Downstate in Brooklyn, his seven years of residency at Mount Sinai, and the two-year plan for a fellowship in Toronto. Neurosurgery is the only profession where you’ve started to have arteriosclerosis before you finish your training."

Madani wields a huge metal clamp, a medieval-looking instrument, with a set of dagger-like points aiming inward. This is a so-called Mayfield device, named after its creator, Dr. Frank H. Mayfield, who made the first prototype in the late 1960s. It is used to hold the patient’s head completely still during the surgery. He positions the points over her temples, taking care not to puncture the band of muscles that encircles this part of the head—to do so would allow her head to shift, disastrously, during the operation. He pushes the clamp together, the points penetrating the skin and touching the bone of the skull. With her head now clamped in the vise jaws, he secures the long